Telestroke & Telecritical Care

In the US, the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009 stimulated the adoption of electronic health records (EHRs) and promoted health information technology (HIT), including the secure exchange of electronic health information.¹ The American Telemedicine Association (ATA) defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.”² The coronavirus disease 2019 (COVID-19) pandemic accelerated the adoption of telemedicine across the US. Even prior to the pandemic, however, telestroke initiatives were leading the way in improving access to acute stroke triage and management in the US.³ Telestroke has quickly spread, with at least 56 networks in 27 states linking a stroke center with local hospitals in the US that lack around-the-clock stroke expertise.⁴ Similarly, the adoption of telecritical care (TCC) has increased from 0.9% in 2003 to approximately 10% in 2016.⁵ During the pandemic, programs have harnessed existing telehealth programs while creating new infrastructure for telehealth to reduce risks for infectious transmission and meet growing demands due to surges of critically ill patients and staff shortages.⁶ This article reviews recent advances in telestroke and TCC and how COVID-19 has affected these services.

Telestroke

Stroke remains a high priority public health problem. Despite clear evidence for improved outcomes, including reduced mortality, with timely use of recombinant tissue plasminogen activator (rtPA) and endovascular thrombectomy for emergent large vessel occlusion (ELVO), access to rtPA is not yet universally available. Only 55% of people in the US have a primary stroke center within a 1-hour drive, and approximately half of these hospitals do not have staff neurologists. Individuals with acute ischemic stroke who present to rural emergency departments are approximately 10 times less likely to receive rtPA than those presenting to urban primary stroke centers.⁷ The field of telestroke developed in the 1990s with the advent of rtPA and a goal of overcoming some of the challenges created by health inequities and geographic disparities.

An acute ischemic stroke encounter is particularly suited to telestroke interventions (Box, Table 1).^8,9

Patients with a severe acute ischemic stroke and an ELVO may need to undergo interfacility transfers for thrombectomy for a higher level of care in a critical care unit.

Acute Care

Although overall outcomes of stroke patients are dependent on stroke systems of care, telestroke programs can be instrumental in providing neurologic assessment, triage, and decision-making related to rtPA administration.³ The 2019 American Stroke Association (ASA) policy statement on interactions within stroke systems of care recommends telemedicine assessment with the National Institutes of Health Stroke Scale (NIHSS) score. This recommendation has the same level of evidence as inpatient assessment (Class I recommendation; level of evidence A).^10,11

Technology and Guidelines

Mobile stroke care capabilities have expanded with access to smartphones, tablets, and laptops and can be conducted via a mobile console, computer cart, or remotely driven robot.³ Advanced telestroke applications can provide users with an easy-to-use interface, picture archiving, communication systems imaging, and clinical notes within a single software program integrated with EHRs for documentation and billing. The ATA guidelines include recommendations on providing assessments, diagnosis, management, documentation, technologic support, and training among other key aspects for a telestroke program and network.¹²

Although technologic advances have made the adoption and dissemination of telestroke services easier, the widespread adoption of telestroke has been impeded by licensing, credentialing, reimbursement, and liability issues. Statutory and regulatory requirements vary from state to state.¹³

Telestroke Outcomes

Protocol violations in rtPA administration are rare in local hospitals that are a part of telestroke networks, and multiple telestroke networks have shown telethrombolysis increases access to rtPA without increasing the risk of intracerebral hemorrhage compared with in-person stroke consultations.^9,13-15 Telestroke also facilitates appropriate triage and transfer. For example, implementating telestroke in both a South Carolina network and the Arizona Mayo Clinic hub-and-spoke model, resulted in fewer patient transfers.^9,14 Access to telestroke and neurologists improves outcomes including mortality.^3,16

In addition to improving access to clinical care, telestroke networks have also improved access to clinical trials for the centers within the network.¹⁷

Cost-Effectiveness

There are limited studies of cost-effectiveness of telestroke. Studies that have used decision-analysis modeling have shown cost-savings for health systems by increasing the number of patients discharged home.⁷

COVID-19 and Telestroke

COVID-19 has been associated with an increased risk of stroke (See Stroke and COVID-19 in this issue).¹⁸ There have been concerns regarding lower incidence of stroke alerts possibly caused by patients not presenting to hospitals out of fear of contracting COVID-19.^19,20 Other reports suggest this may have been driven in part by a redistribution of which hospitals patients with stroke symptoms present to during the COVID-19 pandemic.²¹

Telerehabilitation

Telerehabilitation is a promising area for poststroke recovery. A recent Cochrane database systematic review included 22 trials (n=1,937 total participants) of telerehabilition for stroke, although it was difficult to draw conclusions about efficacy because the interventions and comparators varied greatly across studies. Nevertheless, there is at least low- or moderate‐level evidence suggesting telerehabilitation is as or more effective as in-person rehabilitation.²²

TCC

In 2014, the TeleICU Committee of the Society of Critical Care Medicine (SCCM) published a review of TCC, and there has since been a rapid growth in related studies. A 2019 update of the SCCM review recommended use of the term TCC, accommodating the concept that TCC services are not necessarily confined to a physical location (eg, the intensive care unit [ICU] or hospital).²³

The American TeleMedicine Association (ATA) defines tele-ICU as the critical care application of telemedicine.” The terms tele-ICU, virtual ICU, and remote ICU all refer to the same care concept: a centralized or remotely based critical care team connected to a bedside ICU team and patient using state-of-the-art audiovisual communication and computer systems.²

TCC Models

There are several different types of models of TCC, for which comparative effectiveness data are not yet available (Table 2).^2,23 The centralized hub-and-spoke model is also termed the continuous care model by the ATA. In this model, a single hub provides TCC to multiple localities simultaneously. A variant of this model is the hub-node-spoke structure used by the Veterans Affairs (VA) Administration, the Military Health System, and some large civilian TCC programs. The hub has dedicated staff with only occasional or no staffing responsibilities at the spokes. Patients are monitored continuously by the intensivist. Software programs generate notifications and include clinical support algorithms. A decentralized care model tends to be consultative or episodic and is also called a “point-to-point system.” In this model, a remote intensivist virtually reviews a single patient at a time at any given location. Providers can connect virtually from any convenient location. A hybrid structures uses the centralized hub-and-spoke structure for critical care with point-to-point subspecialist consultation (eg, psychiatry or stroke neurology). Another model described in the ATA guidelines² is responsive (reactive) in which virtual visits are prompted by an alert via a page, telephone call, or monitoring platform. The ATA recommends that each teleICU/ICU program should include a predetermined chain-of-command process for escalation of emergent situations. The ATA guidelines² provide details on organization, documentation, training, quality improvement, and research for TCC or tele-ICU programs. In addition, it is imperative that patients and families are educated about the involvement of TCC services, equipment, and expectations.

TCC Outcomes

Studies evaluating telemedicine and patient outcomes (eg, length of stay, mortality, transfers, and complications) have shown divergent results.

Mortality. ICUs with observed-to-expected mortality ratio of less than 1 may not experience mortality benefit from TCC, but those with observed-to-expected mortality rates greater than 1 may experience a mortality benefit with telecritical care.²⁴ This association could be due to TCC-mediated performance improvement, increased access to physician or nursing support, or standardization of processes.²⁴ Hospitals that adopted TCC vs those that had not have been shown to have a small but statistically significant reduction in 90-day mortality odds (odds ratio[OR], 0.96; 95% CI: 0.95, 0.98; P<0.001). However, only 12% of hospitals experienced significant mortality reduction, and these were urban hospitals with high admission volumes (>1,000/year). This finding is counterintuitive to the expectation that TCC mostly benefits small rural hospitals where critical care expertise is limited or absent.²⁵

Hospital Transfers. Telemedicine has the potential to enhance emergency medical services by expediting triage, helping initiate management prior to transfer, expediting urgent patient transfers, improving the quality and accuracy of remote consultation, and enhancing the supervision of paramedics and nurses.²⁶

Rapid Response Teams (RRTs). The purpose of both TCC and RRT is to improve care, identify high-risk patients and prevent deterioration of their conditions, and decrease ICU utilization and cost. In a retrospective observational study, TCC was used to support RRT and found to be cost-effective.²⁷

Performance Improvement. A key purpose of TCC is to help standardize practices, making it well suited to quality improvement projects. Studies have evaluated how TCC can improve adherence to evidence-based medical guidelines lung-protective ventilation,²⁸ ordering deep venous thrombosis prophylaxis in all appropriate patients, and evaluating the need for continued use of restraints.

Cost. The cost of setting up a TCC program can range from $1 to $7 million dollars.^29,30 Annual operating costs range from $3 to $3.5 million dollars.³⁰ There are challenges in reimbursing for TCC services, but several studies have shown cost savings from TCC.³¹

Barriers to Use. Widespread adoption of TCC has similar barriers as telestroke, including cost, variable licensure, credentialing and privileging requirements governed by inconsistent federal and state laws, medical staff bylaws, and the American Medical Association. Technologic acceptance by the frontline staff particularly nursing may be challenging, and some may perceive TCC to be intrusive or an invasion of privacy.¹

TCC and COVID-19

The COVID-19 pandemic and rapid increase in the number of critically ill individuals overwhelmed ICU resources at several hospitals and health systems. Critical care teams were augmented with noncritical care-trained team members. TCC provided promising avenues for oversight of tiered team models. The Centers for Medicare and Medicaid Services (CMS)³² expanded access to telehealth services, and states relaxed licensing and credentialing requirements. These changes facilitated expansion of TCC services from rural or underserved areas to more widespread areas to fill gaps in the critical care workforce.

Family visitation had to be limited for safety reasons, and several hospitals resorted to virtual platforms for conducting family meetings. TCC resources were used for consultants from palliative care. TCC was leveraged for pandemic surge planning and redefining typical ICU staffing models in a design meant to improve workforce efficiencies and conserve personal protective equipment (PPE) by augmenting in-person critical care teams with a TCC-based intensivist leader.³³ During the pandemic, makeshift TCC platforms were rapidly set up to help with surge planning. If TCC is deployed systematically, it can continue to promote adherence to best practices, improve ICU throughput, and improve communication. Poor implementation, however, could lead to breakdown in communication in a rapidly changing care environment.³⁴

The burden of postintensive care syndrome (PICS), defined as the unintended consequences of critical care in the physical, cognitive, and behavioral domains in COVID-19 survivors is expected to be tremendous. Post-ICU recovery clinics and dedicated COVID-19 centers with multidisciplinary team members such as intensivists, internists, neurologists, pulmonologists, physical and occupational therapists, neuropsychologists, cardiologists, and immunologists among others have also adapted their care delivery models to include in-person as well as telehealth visits.

Conclusion

Telestroke and TCC are promising avenues for improving access to timely care and overcoming geographic disparities. In the midst of a global pandemic, access to telestroke and TCC has proven invaluable for acute care to fill workforce shortages. Potential solutions for overcoming barriers to improve access to these services include support from regulatory bodies, streamlined credentialing and licensing, cost-effective technologies, and streamlined reimbursement for hospitals deploying these services. Future studies should be designed to understand the comparative effectiveness for different models of telestroke and TCC services and for understanding which telehealth models can be implemented effectively during a pandemic.